A miner at the black lung laboratory in the Appalachian Regional Hospital in Beckley, W.Va., has his lung capacity tested. Blood samples were also taken and his heartbeat was monitored while walking on a treadmill. These and other tests were used to determine if miners had coal dust particles in their lungs.

Patty and Gary Quarles lost their son, Gary Wayne Quarles, in the explosion at Upper Big Branch mine. Their son's post-mortem diagnosis indicated he had black lung, a puzzling finding since he was only 33.

It wasn't supposed to happen to coal miners in Mark McCowan's generation. It wasn't supposed to strike so early and so hard. At age 47 and just seven years after his first diagnosis, McCowan shouldn't have a chest X-ray that looks this bad.

"I'm seeing more definition in the mass," McCowan says, pausing for deep breaths as he holds the X-ray film up to the light of his living room window in Pounding Mill, Va.

"The mass is larger and more defined in the right upper lobe," he continues, clinically describing the solid streak that shows up white on the X-ray of his lungs. "If you know white is bad and black is good, I'm in a lot of trouble."

McCowan went from a clean X-ray at age 35 to progressive massive fibrosis — an advanced stage of coal workers' pneumoconiosis, or black lung — in just five years.

"You go from being normal to where ... one day you try to do something you used to do, and you can't do it and you're just heaving to catch your breath," McCowan says. "And you say this is crazy. It can't be this bad. And then you realize a couple months down the road that it can be. And you realize a year down the road after that that you ain't seen nothing yet."

An 'Epidemic' Among Miners

A joint investigation by NPR and the Center for Public Integrity (CPI) has found that McCowan is not alone. Incidence of the disease that steals the breath of coal miners doubled in the last decade, according to data analyzed by epidemiologist Scott Laney at the National Institute for Occupational Safety and Health (NIOSH).

Cases of the worst stage of the disease have quadrupled since the 1980s in a triangular region of Appalachia stretching from eastern Kentucky through southern West Virginia and into southwestern Virginia.

Black lung experts and mine safety advocates have warned of the resurgence of the disease since 1995. New reporting by CPI and NPR reveals the extent to which federal regulators and the mining industry failed to protect coal miners in the intervening years.

An analysis of federal data by CPI and NPR also shows that the mining industry and federal regulators have known for more than two decades that coal miners were breathing excessive amounts of the coal mine dust that causes black lung. CPI and NPR also found that the system for controlling coal mine dust is plagued by weak regulations and inaccurate reporting that sometimes includes fraud.

"This is clearly a public health epidemic," Laney says. "This is a rare disease that should not be occurring. It's occurring at a high proportion of individuals who are being exposed."

Especially shocking to Laney and others focused on black lung is the grip the disease has on younger miners and its rapid evolution to progressive massive fibrosis, or complicated black lung.

At the Upper Kanawha clinic in Cedar Grove, W.Va., the black lung caseload doubled in the last 10 years, according to program coordinator Debbie Wills, and began to include younger miners in their 40s and more serious disease.

"The first 10 years or so that I worked here I had four patients with complicated black lung," says Wills, who has worked at the clinic since 1989. "We knew them all intimately because there were so few of them. Now we have at least 50 diagnosed with complicated black lung."

The autopsies of the 29 victims of the 2010 explosion at what was then Massey Energy's Upper Big Branch mine also show an escalation of cases. Twenty-four of the victims had sufficient lung tissue for testing, and of those, 71 percent had the nodules and lesions on their lungs that signify the disease.

That's a rate 10 times the average for southern West Virginia, says Davitt McAteer, a former federal mine safety chief who led an independent investigation of the explosion, in Raleigh County, W. Va., and reviewed the autopsies.

"What was shocking was the number of miners who showed evidence of black lung," McAteer says, "particularly among younger miners ... and miners who you would not have expected to have black lung."

That includes some victims who spent fewer than 10 years underground and at least two who were only in their 20s.

"It's unbelievable," says Gary Quarles, whose son Gary Wayne Quarles was 33 when he died at Upper Big Branch. His autopsy showed signs of black lung. "Being in the mines for 13 to 15 years and already considered having black lung ... that's uncalled for."

Quarles, who is 55 and spent twice as many years underground, says his chest X-rays are negative for the disease.

Federal Law Aims To Curb Black Lung

The Federal Coal Mine Health and Safety Act of 1969 was supposed to sharply cut exposure to coal mine dust. The act set a standard for coal dust exposure (2 milligrams per cubic meter of air), which was as little as 1/4 of the concentrations miners breathed at the time.

The act's passage followed a 23-day unauthorized and rowdy strike in which 40,000 West Virginia coal miners demanded government efforts to prevent the disease and to compensate victims.

By the end of the year, tough dust exposure limits were in place. Miners were offered free diagnostic chest X-rays every five years, and federal compensation became available.

The X-rays showed 4 in 10 miners tested had black lung. The disease killed 1,800 miners in a single year. But diagnoses soon plunged more than 90 percent, according to NIOSH data.

"They anticipated that no one would develop progressive massive fibrosis," says 84-year-old Donald Rasmussen, a pulmonologist in Beckley, W.Va., who says he's tested 40,000 coal miners in the last 50 years.

"In 1969, I publicly proclaimed that the disease would go away before we learned all about it," he adds. "And I was dead wrong."

Rasmussen first started charting an increase in serious black lung cases about 15 years ago.

"We began to see the appearance of younger miners who had worked in the mines only since the dust suppression following the '69 act that were showing up with complicated pneumoconiosis or progressive massive fibrosis," he says.

Since 1970, NIOSH epidemiologists documented test results for 43 percent of the nation's coal miners. In 1995, the tests began to indicate more and more black long, rapid disease progression and the unexpected occurrence among relatively young miners.

"From the patterns and from the severity, from the prevalence of the disease, this must be a situation in which the dust in many, many mines is simply not adequately controlled," says Edward Petsonk, a pulmonologist at West Virginia University and a consultant for NIOSH. "There's nothing else that could possibly cause this."

Increased Dust Exposure

The new era of coal dust controls was followed by more dust exposure for miners, according to federal data obtained by CPI and NPR. The average workweek for coal miners grew 11 hours in the last 30 years, adding about 600 hours of exposure each year.

"By the time I was 40 years old, I mined more coal than most miners [had] seen in a lifetime," says McCowan.

Production pressure grew with greater demand for coal and higher prices. By 2000, coal production had jumped fivefold from the 1970s. In 2010, it was still triple what it was when the new coal dust limits took effect.

"You can't be exposed to the kind of tonnage that I was and not get black lung disease," McCowan says.

Actually, Petsonk and Rasmussen say, some miners are more susceptible to black lung than others. They can't explain why, but they do say that smoking enhances susceptibility. Still, neither McCowan nor Gary Wayne Quarles was a smoker.

Mining machines also became more powerful and efficient, cutting through coal seams laced with silica-bearing quartz and sandstone, especially in Virginia, West Virginia and Kentucky.

"In the process, they release more silicon dioxide, and the increase in silica is more toxic than just the coal dust itself," Rasmussen says.

Federal records obtained by CPI and NPR under the Freedom of Information Act show thousands of coal miners were exposed to excessive levels of silica in each of the last 25 years. Since 1987, coal mining companies and government inspectors turned in more than 113,000 valid mine dust samples. Roughly 52 percent of those samples exceeded federal standards. In 1998 alone, about 65 percent of the valid silica samples violated the standard.

Silica exposure prompts a call for something that might seem unexpected from the National Mining Association (NMA): more regulation. The industry group wants a crackdown focused specifically on silica in the Appalachian region where black lung is resurgent.

"These people are being exposed [to] three to four times the silica exposures for periods over 20 years. [They have] a chest full of silica and nothing's been done about it," says Bob Glenn, a black lung consultant for NMA.

Excess silica forces mining companies to meet a lower standard for coal dust. The idea is that less exposure to coal dust means less exposure to silica. The federal Mine Safety and Health Administration (MSHA) proposes toughening the coal dust standard by slashing exposure limits in half (to 1 milligram per cubic meter of air).

Mine Dust Standards Vs. Protection

Coal dust measurements taken by MSHA and the industry show that coal mines already meet the lower standard and have for years. But the industry still opposes the new standard because it would broadly apply to coal dust and to all mines everywhere.

In a companion story to the NPR/CPI investigation, veteran coal industry reporter Ken Ward Jr. of The Charleston Gazette reviews 40 years of attempts to strengthen protection for miners.

Ward quotes former MSHA official Celeste Monforton, a worker safety advocate now at George Washington University: "We can't get a regulation out to save our souls." And, as Ward reports, "miners are left with the same system that experts have agreed hasn't worked for decades."

Since 1970, when mine dust controls began, black lung contributed to the deaths of more than 70,000 miners. The federal government and the industry spent $45 billion compensating the victims, including McCowan, and their families.

"Now it feels like I've got a heavy wet sack on each lung," McCowan says, between long, deep breaths. "Breathing has become a conscious effort. ... It seems like I give up a little bit of my world each day, that it gets smaller and smaller."

Simple tasks become enormous challenges — "a Mount Everest every day," he calls it — including holding his 2-year-old grandson.

"I say, 'Little buddy, I got to put you down for a few minutes,'" McCowan says with a deep sigh. "And he's learned to run a little bit. He'll say, 'Run, paw-paw, run.' He wants me to chase him. And I can't."

NPR's Sandra Bartlett and Chris Hamby of the Center for Public Integrity contributed reporting for this story. Research by NPR's Barbara Van Woerkom; editing by NPR's Andrea de Leon and Alicia Cypress.

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Transcript

MELISSA BLOCK, HOST:

From NPR News, this is ALL THINGS CONSIDERED. I'm Melissa Block. And we begin this hour with disturbing news from a joint NPR investigation with the Center for Public Integrity. The disease that steals the breath of coal miners is back with a vengeance, especially in Virginia, West Virginia and Kentucky. Black Lung is afflicting younger miners and advancing more quickly to the worst stage of disease.

Mine safety advocates have warned for years of a resurgence. Still, as NPR's Howard Berkes reports, federal regulators and the coal industry failed to protect miners from the dust that causes Black Lung.

HOWARD BERKES, BYLINE: The freshest indications of the resurgence of Black Lung are found in 24 autopsy reports, like the one on a coffee table in a gray house outside Naoma, West Virginia. Each of its eight stiff and stapled pages list one name in bold black letters. Quarles, Gary Wayne, age 33, cause of death, smoke, soot and blast injury in the explosion two years ago at the Upper Big Branch coal mine.

The details draw soft sobs from Gary Wayne's mother, Patty, who's pant leg hides a tattooed image of her son. But it's an entry on page 6 under significant findings that shocks the lost miner's dad.

GARY QUARLES: He had black lung. Being in the mines for 13 to 15 years and already considered having black lung nowadays, it's unbelievable.

BERKES: Gary Quarles is 55 and spent twice as many years underground. His chest x-rays are negative for black lung, so his son's post-mortem diagnosis is troubling.

QUARLES: And he never smoked. He never smoked a cigarette in a day of his life. And not only him, there's quite a few other younger guys, you know. And being that young, that's uncalled for.

BERKES: Seventy percent of the tested Upper Big Branch miners showed signs of black lung. That's 10 times the miners' rate in southern West Virginia and 20 times the national rate. At least two were in their 20s and some had less than 10 years underground. This defies the change that began in 1969 when 40,000 West Virginia miners walked off the job due to misery and death from black lung.

Some marched raucously on the state capital in Charleston and others cheered Congressman Ken Hechler at a rally.

CONGRESSMAN KEN HECHLER: The greatest heroes are you, the coal miners. You've taken the future, your future, in your hands and you've proclaimed no longer are we gonna live and work and die like animals. We're free men.

BERKES: Charleston cardiologist Isadore Buff called for state and federal action.

ISADORE BUFF: Will the coal miners of West Virginia get compensation for black lung and will the coal mines be cleaned up so that they won't die of this horrible disease? That's the problem. That's what we're trying to do.

BERKES: And by the end of the year, Congress acted, establishing tough limits on coal dust underground. A national compensation program kicked in, along with free chest x-rays. They found that four in 10 coal miners suffered black lung, 1,800 died from it in a single year. But by the mid-1990s, the new coal dust limit seemed to be working. Diagnoses plummeted by more than 90 percent.

DONALD RASMUSSEN: The way the law was intended and the way the program was set up, they anticipated that no one would develop progressive massive fibrosis.

BERKES: That's the worst stage of black lung and pulmonologist Donald Rasmussen has seen it many times in his clinic in Beckley, West Virginia, where he says he's tested 40,000 coal miners in the last 50 years. He's 84 and thought he'd be out of the testing business and retired by now.

RASMUSSEN: Well, in 1969, I publically proclaimed that the disease would go away before we learned all about it and I was dead wrong.

RASMUSSEN: I guess about 15 years ago, we began to see the appearance of younger miners who had worked in the mines only since the dust suppression following the '69 act that were showing up with complicated pneumoconiosis or progressive massive fibrosis.

BERKES: Coal worker's pneumoconiosis is the formal name for black lung and the new trend was also evident at Debbie Wills' clinic in Cedar Grove, West Virginia.

DEBBIE WILLS: The first 10 years or so that I worked here, I had four patients with complicated black lung. We knew them all intimately because there were so few of them. Now we have at least 50 diagnosed with complicated black lung.

BERKES: And in coal mining towns from Pennsylvania to Utah, federal epidemiologists track breath tests and chest x-rays for tens of thousands of miners. They have test results for 40 percent of the nation's coal workers and the findings are dramatic. Basic black lung diagnoses doubled in the last decade. Advanced disease quadrupled since the 1980s in Virginia, West Virginia and Kentucky.

Scott Laney is an epidemiologist at the National Institute for Occupational Safety and Health, or NIOSH.

SCOTT LANEY: Any reasonable epidemiologist would have to consider this an epidemic. I mean, this is a rare disease that should not be occurring. It's occurring at a high proportion of individuals who are being exposed. This is clearly a public health epidemic.

BERKES: Laney says miners are now diagnosed younger and the disease is getting worse quicker.

MARK MCCOWAN: My name's Mark McCowan. I was diagnosed with a complicated form of black lung disease in 2005 when I was 40 years old. Fourteen months later, I took another x-ray and it progressed. After I quit work, the disease has progressed further to the worst kind now.

BERKES: Mark McCowan is 47 now and he looks healthy just sitting there on his living room couch in Pounding Mill, Virginia, but walking his hilly yard, he says, or trying to mow the lawn or simply holding his two-year-old grandson leaves him gasping for air.

MCCOWAN: I say, well, buddy, I got to put you down for a few minutes. And he squirms around a little bit. He'll say, run, papa, run. He wants me to chase him. And I can't. I say, give papa a minute. I might be able to in a minute. And I face Mount Everest every day. Sometimes I make it to the top and sometimes I don't.

BERKES: And like Gary Wayne Quarles, the young victim of the Upper Big Branch explosion, McCowan never smoked. Both worked right at the coal face in the dustiest jobs and both operated gigantic rotating shearers on massive long wall mining machines. But both also worked in an era with strict limits on dust exposure. So what went wrong?

Edward Petsonk is a pulmonologist focused on black lung at NIOSH and West Virginia University.

EDWARD PETSONK: From the patterns and from the severity, from the prevalence of the disease, this must be a situation in which the dust in many, many mines is simply not adequately controlled. There's nothing else that could possibly cause this.

BERKES: Miners are exposed to that coal dust longer because they're spending more time underground, according to federal data. The average work year for coal miners grew 600 hours in the last 30 years.

MCCOWAN: By the time I was 40 years old, I had mined more coal than most miners seen in a lifetime.

BERKES: And as Mark McCowan discovered at one job, more hours came with more efficient mining machines and more pressure to produce.

MCCOWAN: The first year I worked for them was in 1997. They had a record year that year. And since then, they've broken that record. You can't be exposed to the kind of tonnage that I was and not get black lung disease.

BERKES: In fact, the rate of production in coal mines climbed fivefold through the end of the century. Pulmonologists say some miners are more susceptible to black lung and smoking increases susceptibility. But veteran black lung specialist Donald Rasmussen cites something else that makes coal dust more dangerous and black lung more severe.

RASMUSSEN: The mining equipment has grown more and more powerful. They can chew rock. They are now able to mine narrow seams or a seam of coal where there's a strip of rock between, and send that to the cleaning plants and get clean coal out of it. But in the process, they release more silicon dioxide, and the increase in silica is more toxic than just the coal dust itself.

BERKES: Silica is in the quartz and sandstone that is especially prevalent in coal seams in Virginia, West Virginia, and Kentucky, where the resurgence of black lung is greatest. And the average coalminer was exposed to excessive levels of silica in each of the last 25 years, according to federal data. That prompts something a bit unexpected from the coal industry, a call for more enforcement specifically focused on silica.

Bob Glenn is a consultant for the National Mining Association.

BOB GLENN: What needs to be done is an enforcement of the silica standard in those regions there. This is serious. These people are being exposed three to four times the silica exposures for periods over 20 years. So these people - a chest full of silica and nothing's been done about it.

BERKES: The National Mining Association doesn't challenge the notion that black lung is back. But the group opposes tougher limits for coal dust that would affect all coal mines everywhere. Target the problem mines in problem regions, the group says, and smaller mines that present the biggest threats. Still, some large operations also have coal and silica dust issues.

Mark McCowan worked at one of the biggest coal mines in Virginia, where the coal seam coursed through rock.

MARK MCCOWAN: Sometimes the coal was reduced to a two-inch thickness and you have to stay with that two inches because you know that's your coal seam. But the rest of what you need to mine may be solid rock.

BERKES: Federal regulators want to toughen the coal dust standard by cutting the exposure limit in half. They say that will also cut exposure to silica. But here's the thing, federal and industry data show coal mines on average already meet the lower standard for coal dust. So something is not right with the standard or the data, because black lung continues to ruin more lives.

MCCOWAN: Now it feels like I've got a heavy wet sack on each lung. Breathing has become a conscious effort. Some days, I'm consciously feeling how heavy my lungs are and that it's not getting no better. It seems like I give a little bit up of my world each day, that it gets smaller and smaller.

BERKES: Since 1970, black lung killed or helped kill 70,000 coalminers. Tomorrow on NPR's MORNING EDITION: how government failed to control coal dust, how the exposure limits were weak from the very beginning, and how industry gamed the system that was supposed to protect Mark McCowan, Gary Wayne Quarles and thousands of others.

Howard Berkes, NPR News.

(SOUNDBITE OF MUSIC)

BLOCK: At NPR.org, you can see the working life of coalminers as captured by photojournalist Earl Dotter. And there are links to more reporting from the Charleston Gazette on failed efforts to toughen mine dust regulations. Transcript provided by NPR, Copyright NPR.